1. Obsessive Compulsive Disorder and OC Spectrum Disorders
J. Hancey, MD
Dept. of Psychiatry
Oregon Health Sciences University

2. The many faces of OCD
Dermatologist: Chapped hands, eczema, Trichotillomania
Oncologist/Infectious disease: Hypochondriasis (Cancer, AIDS)
Neurologist: OCD associated with Tourette’s or other neurologic disorders
Obstetrician: OCD during pregnancy or postpartum
Pediatrician: Compulsive behavior, OCD secondary to Sydenham’s chorea, difficulty in school
Plastic surgeon: Body dysmorphic disorder
Dentist: Gum lesions from excessive teeth bleeding
Family practitioner: Report of family member washing or checking excessively, comorbid affective or anxiety disorders, all of the above.

3. Definitions of OCD An anxiety disorder characterized by: Obsessions
Recurrent and persistent ideas, impulses, thoughts, images that are intrusive and sometimes senseless
Compulsions
Repetitive, seemingly purposeful behaviors performed in response to an obsession (e.g., ritualistic or stereotypic behavior)
Anxiety arises around resistance to obsessions and/or compulsions
Anxiety may or may not be the primary feature of OCD

4. Diagnostic Criteria for OCD
Either obsessions or compulsions
Recognized by patients as excessive or unreasonable
Obsessions or compulsions cause marked distress, are time consuming, or significantly interfere with functioning
DSM-IVtm 1994:

5. Obsessive-Compulsive Spectrum Disorders
Preoccupations with bodily sensations or appearance
Body Dysmorphic Disorder Depersonalization Anorexia nervosa Hypochondriasis
OCD
Tourette’s syndrome Sydenham’s chorea Torticollis Autism
ADHD
Sexual compulsions Trichotillomania Pathological gambling Kleptomania Self-injurious behavior
Neurologic disorders
Impulsive disorders
Hollander et al, J Clin Psychiatry, 1966

6. Epidemiology of OCD 6-month point prevalence: 1.6%
Life-time prevalence: 2.5%
An estimated 3.9 million Americans had OCD in 1990
4th most common psychiatric disorder
Double that of panic disorder or schizophrenia

9. Biological Differences of OCD
Anatomy
decreased caudate nucleus volume
Biochemistry
increased CSF 5-HIAA
Physiology
increased frontal and pre-orbital glucose utilization

10. Precipitating Factors
25%--depression and/or anxiety accompanied the initial symptoms
50% - 60%--stressors around the time of onset of symptoms
--pregnancy
--childbirth
--sexual problems
--death in family
Streptococcal pharyngitis

11. The Streptococcal Connection
Increasing evidence for an autoimmune etiology
Group A beta hemolytic streptococcus
Antineuronal antibodies
Genetic vulnerability
D8/17 positivity as a marker

12. PANDAS Pediatric Autoimmune Neuropsychiatric Disorders Associated with
Streptococcal infections

13. Treatment
Medications
Cognitive Behavioral Therapy

14. COGNITIVE THERAPY

15. Cognitive Therapy Re-label Re-attribute Re-focus Re-evaluate
Schwartz, J. Brain Lock
Pearl: Use a “mental garbage can”.

16. BEHAVIOR THERAPY

18. Behavior Therapy Effective behavior therapy involves
Exposure: facing feared or avoided object, thought, situation, or place, preferably in vivo
Response or ritual prevention: delaying and diminishing anxiety-reducing compulsions

19. SUD’S List: (Subjective Units of Distress)
List compulsive behaviors
Assign SUD’s value to each (0-100)
Rank order from top to bottom
Begin at the bottom of the list
Best source: Baer, Lee. Getting Control.
Pearl: Break up complex rituals into various parts

20. Serotonin Reuptake Inhibitors in the Treatment of Obsessive Compulsive Disorder

22. Fluoxetine vs Clomipramine
20 week crossover
No difference between Y~BOCS
Delayed response to 2nd drug
Relapse occurred during washout
<ADR with fluoxetine
ADR = adverse drug reaction
Pigott et al. Arch Gen Psychiatry, 1990;47:

26. Factors Affecting Serum Drug Levels
Absorption
Protein binding
Metabolism
Elimination

27. Utilizing P450 Inhibition
1A2
2D6
CMI
Desmethyl CMI
inactive

28. The Role of Anxiolytics When, What, and When to Worry
Initial stages of treatment, prn
BZD’s - the long and short of it
abuse, dependence and addiction

29. Benzodiazepine Issues
Abuse
Physical dependence
Addiction

30. Treatment Strategies
SSRI beginning at low doses, gradually increasing to maximum doses
minimum 10 week trial
switch SSRIs
augmentation
clonazepam
atypicals
opioid agonism/antagonism
acamprosate
cognitive-behavioral therapy
surgery

32. Gamma Knife